Provider Demographics
NPI:1578503785
Name:BROCKWELL, RUSSELL C (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:C
Last Name:BROCKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 NE 21ST ST
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1045
Mailing Address - Country:US
Mailing Address - Phone:239-776-6096
Mailing Address - Fax:
Practice Address - Street 1:2950 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3625
Practice Address - Country:US
Practice Address - Phone:954-659-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98102207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000007602OtherBLUE CROSS
AL009916165Medicaid
AL009916175Medicaid
MS06857292OtherMISSISSIPPI MEDICAID
AL42512OtherHEALTHSPRING
AL000007604OtherBLUE CROSS
AL000007609OtherBLUE CROSS
AL050065291OtherRAILROAD MEDICARE
AL000007609Medicaid
AL010033CG86101OtherSECTION 1011
ALG86101OtherVIVA
AL000007604OtherBLUE CROSS
AL000007609Medicaid
AL000007602OtherBLUE CROSS